Urological Cancers

Question 1

When is NICE 2WW referral made for haematuria?

Answer 1

If patient over or is 45 with unexplained visible haematuria (no UTI) OR visible haematuria that persists/recurs after successful treatment of UTI (Bladder/Renal cancer)

If patient over or is 60 with unexplained non visible haematuria ALONG WITH dysuria/WCC. Routine referral in this age group if they keep getting UTIs.

Question 2

What further investigations are done for haematuria?

Answer 2

First line: Flexible cystoscopy
Also: CT urogram/CT IVU with contrast or US KUB

Mainly due to bladder cancer out of all urological cancers

Question 3

What does bladder cancer usually present with?

Answer 3

Painless visible haematuria

Question 4

What are the 2 types of bladder cancers?

Answer 4

TCC: Western world more common, smoking biggest cause
SCC: Africa and places with widespread schistosomiasis as that’s what routinely causes it along with chronic inflammation

Question 5

How is bladder cancer staged?

Answer 5

TNM Staging - T1 is non-muscle invasive while T2 and above is muscle invasive (past muscularis layer)

Question 6

What investigation is first line for bladder cancer?

Answer 6

Urgent flexible cystoscopy under local anaesthetic
If suspicious lesion found: Rigid cystoscopy with bipsy under GA
If muscle invasive cancer suspected, CT staging done with CTIVU/USKUB

Question 7

How is non-muscle invasive bladder cancer managed?

Answer 7

Transurethral resection of bladder tumour with or without mitomycin C/BCG

Question 8

How is muscle invasive bladder cancer managed?

Answer 8

Radical cystectomy with/out neoadjuvant chemotherapy and then bladder reconstruction/ileal conduit.

If locally advanced/metastatic, chemotherapy

Question 9

Where does prostate cancer usually occur and what are risk factors?

Answer 9

Peripheral zone of prostate (adenocarcinomas).
Risk factors: age, obesity, Afro-Caribbean, FHx

Question 10

What are clinical features of prostate cancer?

Answer 10

Usually asymptomatic - can present with LUTS (lower urinary tract symptoms), haematuria and urinary retention
Examination: hard palpable nodule, hard and craggy irregular gland
Bloods: Raised PSA (absent in 15% of people)

Question 11

How is prostate cancer investigated?

Answer 11

If raised PSA or abnormal DRE, refer for 2WW referral to urology. This is reviewed by urologist in PSA clinic to decide whether to MRI or not. Multiparametric MRI of prostate is performed and if abnormal, transperineal prostate biopsy.

Question 12

When is PSA testing done?

Answer 12

To detect prostate cancer where treatment can be curative or extend life. It does not distinguish between aggressive and non-aggressive cancer.

Question 13

What can raise PSA?

Answer 13

BPA, Trauma and Infection

Question 14

Who is PSA testing offered to?

Answer 14

Men over 50 who request it or in men with suspected prostate cancer

Question 15

When can PSA testing be done?

Answer 15

6412 BIDE
6 wweks after prostate biopsy
4 weeks after UTI/Prostatitis
1 week after DRE
2 days after vigorous exercise/ejaculation

Question 16

How is prostate cancer staged?

Answer 16

Stage 1: non-palpable, only detected by microscope
Stage 2: palpable, confined within capsule
Stage 3: locally advanced, breaching the capsule and invading seminal vesicles/fat
Stage 4: invading adjacent organs with bony mets

Question 17

How is prostate cancer graded?

Answer 17

Gleason Score (1-5) - describes differentiation of cells, most common and second most common pattern graded (3+4 or 4+3)
The higher the score, the more poorly differentiated

Question 18

How is localised prostate cancer managed?

Answer 18

Low risk (PSA<10, Gleason below 6, TNM 1-low2): Active surveillance
Intermediate risk (PSA 10-20, Gleason 7, TNM high 2): Prostatectomy
High risk: Prostatectomy and conformal deep xray therapy

Question 19

What are risk factors for testicular cancer?

Answer 19

Undescended testes, FHx, Hypospadias, HIV

Question 20

Who are teratomas and seminomas more common in?

Answer 20

Teratoma: mis-20s, AFP and bHCG rise
Seminoma: mid-30s, AFP normal

Question 21

How does testicular cancer present?

Answer 21

Painless lump (lymphadenopathy, abdominal pain and weight loss suggest metastatic)

Question 22

How is testicular cancer investigated?

Answer 22

To diagnose: US testes, LDH, AFP and bHCG
To stage: CTCAP

Question 23

How is testicular cancer managed?

Answer 23

2WW referral
Initial treatment: Radical inguinal orchidectomy
Chemotherapy/Radiotherapy

Question 24

What can a scrotal lump that one can’t get above indicate?

Answer 24

Inguinal hernia
Proximally extending hydrocoele

Question 25

What does a painful swelling of scrotum indicate?

Answer 25

Testicular torsion
Torsion of testicular appendix
Epididymo-orchiditis

Question 26

What can a scrotal lump where testis can be localised from swelling indicate?

Answer 26

Epididymitis
Varicocoele

Question 27

What does a transilluminable swelling indicate?

Answer 27

Hydrocoele
Epididymal cyst

Question 28

How does testicular torsion present?

Answer 28

Bell-clapper deformity
High-riding testicle
No cremasteric reflex
Pain

Question 29

How does an epididymal cyst present?

Answer 29

Multiple small lumps at top and back of testes

Question 30

How does epidiymo-orchitis present?

Answer 30

Sore testes, discharge and fever